TN 9 (02-11)

HI 03001.020 Eligibility for Extra Help (Prescription Drug Low-Income Subsidy)

Citations:

Section 1860D-14 of the Social Security Act;

Regulations 20 CFR 418.3101

A. Introduction to Medicare Part D eligibility

Under the provisions of the Medicare Part D program, Medicare beneficiaries entitled to Medicare Part A or Part B, or both, may enroll in the Medicare Part D prescription drug program through a Medicare prescription drug provider (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD) to obtain assistance with the purchase of covered medication. While Part D provides for discount prescription drugs, beneficiaries usually pay certain premiums, deductibles, and copayments.

Individuals eligible for Extra Help may receive full or partial help with their Part D premiums, pay a reduced or no deductible, and be responsible for smaller copayments.

B. Basic requirements for Extra Help eligibility

If the beneficiary is alive and meets all of the following conditions, he or she may be eligible to receive full or partial Extra Help:

  • Entitled to Medicare Part A (Hospital Insurance) or Medicare Part B (Supplementary Medical Insurance), or both;

  • Resides in one of the 50 States or the District of Columbia;

  • Not incarcerated;

  • Has income (including a living-with spouse’s income) that is less than 150% of the Federal Poverty Level (FPL), based on household size (HI 03020.055);

  • Has resources (including a living-with spouse’s resources) that are within the specified limits for eligibility (HI 03030.025);

  • Files an application (or is deemed eligible, as described in HI 03010.005B.2.f.) with SSA or with a State Medicaid Agency (HHS’ regulations encourage States to use the SSA process by completing the applications for Medicare Part D Extra Help, either the SSA-1020-OCR or i1020 and submit the application to us for processing); and

  • Enrolls with a PDP or MA-PD.

NOTE: For applications effectively filed January 1, 2010, or later, and initial determinations effective on or after January 1, 2010, in-kind support and maintenance (ISM) does not count as income and for purposes of determining eligibility for Extra Help, the cash surrender value of life insurance does not count as resources.

C. Income limits

1. General description of income limits

We base income limits on the FPL published in the Federal Register by the Department of Health and Human Services (HHS). Regardless of the age of family members, poverty levels remain the same.

Income after exclusions, whether earned and unearned, must be less than 150% of the FPL (based on size of the household) for subsidy eligibility.

2. Separate FPL for Alaska and Hawaii

One set of poverty levels applies to the 48 contiguous States and the District of Columbia. Alaska and Hawaii have separate and slightly higher poverty levels.

When an individual applies for Extra Help, we apply the FPL that corresponds to the individual's State of residence in the month that he or she files the application. We program the system to compute eligibility using the correct poverty levels for the applicable State of residence.

Moving to a State that has a higher or lower FPL is not a subsidy-changing event (SCE) and does not require a redetermination.

REMINDER: Be alert to situations where a move is the result of an SCE; e.g., an individual's spouse dies and the individual moves to live with an adult child. (For detailed information regarding SCEs, see HI 03050.005).

3. 2014 FPL table

  1. 48 States and the District of Columbia

Family Size

100%

135%

140%

145%

150%

1

$11,670.00

$15,754.50

$16,338.00

$16,921.50

$17,505.00

2

$15,730.00

$21,235.50

$22,022.00

$22,808.50

$23,595.00

3

$19,790.00

$26,716.50

$27,706.00

$28,695.50

$29,685.00

4

$23,850.00

$32,197.50

$33,390.00

$34,582.50

$35,775.00

5

$27,910.00

$37,678.50

$39,074.00

$40,469.50

$41,865.00

6

$31,970.00

$43,159.50

$44,758.00

$46,356.50

$47,955.00

7

$36,030.00

$48,640.50

$50,442.00

$52,243.50

$54,045.00

8

$40,090.00

$54,121.50

$56,126.00

$58,130.50

$60,135.00

9

$44,150.00

$59,602.50

$61,810.00

$64,017.50

$66,225.00

10

$48,210.00

$65,083.50

$67,494.00

$69,904.50

$72,315.00

Additional

$4,060.00

$5,481.00

$5,684.00

$5,887.00

$6,090.00

  1. Alaska

Family Size

100%

135%

140%

145%

150%

1

$14,580.00

$19,683.00

$20,412.00

$21,141.00

$21,870.00

2

$19,660.00

$26,541.00

$27,524.00

$28,507.00

$29,490.00

3

$24,740.00

$33,399.00

$34,636.00

$35,873.00

$37,110.00

4

$29,820.00

$40,257.00

$41,748.00

$43,239.00

$44,730.00

5

$34,900.00

$47,115.00

$48,860.00

$50,605.00

$52,350.00

6

$39,980.00

$53,973.00

$55,972.00

$57,971.00

$59,970.00

7

$45,060.00

$60,831.00

$63,084.00

$65,337.00

$67,590.00

8

$50,140.00

$67,689.00

$70,196.00

$72,703.00

$75,210.00

9

$55,220.00

$74,547.00

$77,308.00

$80,069.00

$82,830.00

10

$60,300.00

$81,405.00

$84,420.00

$87,435.00

$90,450.00

Additional

$5,080.00

$6,858.00

$7,112.00

$7,366.00

$7,620.00

  1. Hawaii

Family Size

100%

135%

140%

145%

150%

1

$13,420.00

$18,117.00

$18,788.00

$19,459.00

$20,130.00

2

$18,090.00

$24,421.50

$25,326.00

$26,230.50

$27,135.00

3

$22,760.00

$30,726.00

$31,864.00

$33,002.00

$34,140.00

4

$27,430.00

$37,030.50

$38,402.00

$39,773.50

$41,145.00

5

$32,100.00

$43,335.00

$44,940.00

$46,545.00

$48,150.00

6

$36,770.00

$49,639.50

$51,478.00

$53,316.50

$55,155.00

7

$41,440.00

$55,944.00

$58,016.00

$60,088.00

$62,160.00

8

$46,110.00

$62,248.50

$64,554.00

$66,859.50

$69,165.00

9

$50,780.00

$68,553.00

$71,092.00

$73,631.00

$76,170.00

10

$55,450.00

$74,857.50

$77,630.00

$80,402.50

$83,175.00

Additional

$4,670.00

$6,304.50

$6,538.00

$6,771.50

$7,005.00

4. 2013 FPL table

  1. 48 States and the District of Columbia

    Family Size

    100%

    135%

    140%

    145%

    150%

    1

    $11,490.00

    $15,511.50

    $16,086.00

    $16,660.50

    $17,235.00

    2

    $15,510.00

    $20,938.50

    $21,714.00

    $22,489.50

    $23,265.00

    3

    $19,530.00

    $26,365.50

    $27,342.00

    $28,318.50

    $29,295.00

    4

    $23,550.00

    $31,792.50

    $32,970.00

    $34,147.50

    $35,325.00

    5

    $27,570.00

    $37,219.50

    $38,598.00

    $39,976.50

    $41,355.00

    6

    $31,590.00

    $42,646.50

    $44,226.00

    $45,805.50

    $47,385.00

    7

    $35,610.00

    $48,073.50

    $49,854.00

    $51,634.50

    $53,415.00

    8

    $39,630.00

    $53,500.50

    $55,482.00

    $57,463.50

    $59,445.00

    9

    $43,650.00

    $58,927.50

    $61,110.00

    $63,292.50

    $65,475.00

    10

    $47,670.00

    $64,354.50

    $66,738.00

    $69,121.50

    $71,505.00

    Additional

    $4,020.00

    $5,427.00

    $5,628.00

    $5,829.00

    $6,030.00

  2. Alaska

    Family Size

    100%

    135%

    140%

    145%

    150%

    1

    $14,350.00

    $19,372.50

    $20,090.00

    $20,807.50

    $21,525.00

    2

    $19,380.00

    $26,163.00

    $27,132.00

    $28,101.00

    $29,070.00

    3

    $24,410.00

    $32,953.50

    $34,174.00

    $35,394.50

    $36,615.00

    4

    $29,440.00

    $39,744.00

    $41,216.00

    $42,688.00

    $44,160.00

    5

    $34,470.00

    $46,534.50

    $48,258.00

    $49,981.50

    $51,705.00

    6

    $39,500.00

    $53,325.00

    $55,300.00

    $57,275.00

    $59,250.00

    7

    $44,530.00

    $60,115.50

    $62,342.00

    $64,568.50

    $66,795.00

    8

    $49,560.00

    $66,906.00

    $69,384.00

    $71,862.00

    $74,340.00

    9

    $54,590.00

    $73,696.50

    $76,426.00

    $79,155.50

    $81,885.00

    10

    $59,620.00

    $80,487.00

    $83,468.00

    $86,449.00

    $89,430.00

    Additional

    $5,030.00

    $6,790.50

    $7,042.00

    $7,293.50

    $7,545.00

  3. Hawaii

    Family Size

    100%

    135%

    140%

    145%

    150%

    1

    $13,230.00

    $17,860.50

    $18,522.00

    $19,183.50

    $19,845.00

    2

    $17,850.00

    $24,097.50

    $24,990.00

    $25,882.50

    $26,775.00

    3

    $22,470.00

    $30,334.50

    $31,458.00

    $32,581.50

    $33,705.00

    4

    $27,090.00

    $36,571.50

    $37,926.00

    $39,280.50

    $40,635.00

    5

    $31,710.00

    $42,808.50

    $44,394.00

    $45,979.50

    $47,565.00

    6

    $36,330.00

    $49,045.50

    $50,862.00

    $52,678.50

    $54,495.00

    7

    $40,950.00

    $55,282.50

    $57,330.00

    $59,377.50

    $61,425.00

    8

    $45,570.00

    $61,519.50

    $63,798.00

    $66,076.50

    $68,355.00

    9

    $50,190.00

    $67,756.50

    $70,266.00

    $72,775.50

    $75,285.00

    10

    $54,810.00

    $73,993.50

    $76,734.00

    $79,474.50

    $82,215.00

    Additional

    $4,620.00

    $6,237.00

    $6,468.00

    $6,699.00

    $6,930.00

5. Special procedures when the annual FPL table rates are unavailable for subsidy determinations

The annual FPL table rates are generally published in the Federal Register and available for program use in late January (e.g., 01/2014). The Medicare Application Processing System (MAPS) cannot use the Title II COLA monthly benefit credited (MBC) to determine subsidy amounts until after publication of the annual FPL table rates. Consequently, the subsidy determination program uses the MBC effective November (e.g., 11/2013), until the new table rates are available.

You must use special procedures for Title II beneficiaries whose month of entitlement is December or later, because these beneficiaries do not have an MBC for November. For these beneficiaries, MAPS will either:

  • Deny the application if the resources exceed the current limits: in 2014, $13,440 for a single beneficiary and $26,860 for a couple (systems includes the $1500 per person for burial expenses); or

  • Award the application if the subsidy level is 135% or less using prior year’s FPL table rates.

If neither of the situations in the two prior bulleted items applies to the claimant, MAPS places the application in “Hold” status, pending receipt of the new FPL table.

Cases in “Hold” status receive the following messages dependent upon the following actions:

  • When you click on the “Submit to Subsidy Determination” button on the Development Worksheet (DWMP) screen, you receive the message: “Application is Pending – Awaiting Federal Poverty Level Table Update.”

  • When you query the current application status, both the “Application Data” and “Status” sections on the Query (QDIS) screen reflect the message: “Awaiting Federal Poverty Values for the Current Year.

  • The “Query Sub Menu” (QSMS) screen reflects the same message as the “Application Data” and “Status” sections on the QDIS screen: “Awaiting Federal Poverty Values for the Current Year.”

6. FPL percentage and the amount of Extra Help (premium subsidy)

We determine the amount of a beneficiary’s Extra Help with Part D, also known as the premium subsidy, by the relationship of his or her income (and that of his or her living-with spouse) to the appropriate FPL. For instance, if an individual or couple has income less than 135% of the FPL (and resources are below the specified limit for an individual or couple), they may be eligible for 100% premium subsidy. For a detailed explanation of income limits, see HI 03020.055.

The percent of subsidy assistance depends on the level of income, as shown in the following chart.

Countable Income is:

Premium
Subsidy

Up to 135% of FPL

100%

More than 135% FPL, but not more than 140%

75%

More than 140% FPL, but not more than 145%

50%

More than 145% FPL, but less than 150%

25%

150% FPL or more

None

NOTE: We limit low-income premium subsidies to the greater of the lowest plan premium or the CMS-set “benchmark” amount in the person’s area. Therefore, a person with income below 135% of the FPL may still be responsible for paying a portion of the plan’s premium if he or she enrolls in a plan whose premium exceeds the area benchmark. Refer all questions regarding premiums to the PDP or MA-PD provider.

D. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603001020
HI 03001.020 - Eligibility for Extra Help (Prescription Drug Low-Income Subsidy) - 02/04/2014
Batch run: 02/04/2014
Rev:02/04/2014